The following article was published in the Village Voice in June 1975. Sub-headings have been added for ease of reading.

The argument over circumcision: The case against

by Sylvia Topp

Circumcision is the only preventive operation left in

American medicine; the automatic removal of tonsils,appendix and adenoids went out of style years ago.

If you’re the parents of a boy, chances are you had him circumcised – over 80 per cent of American parents do. And chances are you had him circumcised without giving it a second thought. But is there any other part of your child’s body you would automatically let a doctor remove? And without an anaesthetic?

I decided not to circumcise my son when he was born four years ago, and since then I have wondered why parents are so docile in accepting such a bizarre operation. It amazes me that they think nothing of letting their child experience, as one of his first sensations in life, what must be the horrible pain and traumatic shock of being held down and having apiece of his penis cut off. And they don’t even ask why.

In preparation for this article I read all the current journal literature on circumcision. I interviewed by telephone, at random, 10 per cent of Manhattan’s obstetricians; I questioned many recent mothers of boys; and I talked to every man I could find who had either not been circumcised at all or had been circumcised later than infancy.

The blame game

What shocked me most was that over half Manhattan’s obstetricians consider circumcision unnecessary. Yet they continue to circumcise over 90 per cent of the boys they deliver because they believe it’s useless to try to convince the parents not to. In fact, most of them don’t even try. Yet two-thirds of the mothers I interviewed said they would not have had their sons circumcised if their doctor had advised against it, and the others were not sure.

Origins of circumcision

The theories of the origin of circumcision are numerous and confusing. The practice is firmly based in history, which is one of the reasons no questions are asked. A practical theory is that the original people practising circumcision lived in arid conditions where the operation had appeal as a prophylactic measure against balanitis (inflammation of the head of the penis), since sand might collect under the foreskin and be hard to get out, given the scarcity of water (Leitch 1970).

Some think circumcision stems from the primitive custom of carrying off parts of the body – the Indians took skulls, others took genitals – of a defeated enemy as a trophy or testimony of manly prowess in battle. It may also have roots in the ritual castration practised in ancient matriarchal religions, but since castration inherently (and sharply) limits the perpetuation and growth of a people, a token mutilation, such as circumcision, was found far more practical (Bolande 1969).

Freud also viewed circumcision as a symbol of castration, but as an act perpetrated by the father out of fear and jealousy of the son. Others claim that circumcision represents a subconscious wish on the part of the male to become female.

In some societies circumcision is performed to reduce what is considered excess sexual energy, thus having a civilizing effect; in others it proves an adolescent’s ability to endure pain and thereby be accepted as an adult (Morgan 1965).

Circumcision is practised by only one sixth of the world’s population – throughout the near east and parts of Africa, among the Moslems of India and south-east Asia, by the Australian Aboriginals and some Polynesians, and by some Indians of north and south America (Gairdner 1949).

Circumcision in the United States

The American practice was taken from the Jews, who began arriving here in large numbers from eastern Europe at the end of the nineteenth century. Christians had not practised circumcision since the teachings of St Paul actually dissuaded them from it. And it wasn’t until the twentieth century that doctors started developing theories that circumcision was medically beneficial. Although it caught on to some extent in England, Australia and Canada, the United States was the only western country where circumcision became really popular. It never became the prevailing custom in any European country but England. Its popularity has been decreasing in England, Australia and Canada for some years now, and I hope that America will soon join that trend. Although the American Academy of Pediatrics issued a statement of policy in October 1972 which began: “Neonatal circumcision should not be considered a routine procedure”, there has been little noticeable change in the circumcision policy in this country so far.

Functions of the foreskin

Because hardly anyone in this country has ever seen a foreskin, it might be well to describe its function. The foreskin protects the head of the penis, or glans, keeping it moist and sensitive at all times. It is drawn back during an erection or sexual intercourse (and for cleaning purposes), so the otherwise unexposed glans, which is provided with special sensory receptors for appreciating pleasurable sensations, is stimulated only during these times. During intercourse the foreskin is pushed back and forth, at times forming a wide ring at the base of the penis – a sort of natural French tickler. When the foreskin has been removed, the head of the penis is constantly stimulated and loses much of its sensitivity; it dries out, and the skin becomes tough by necessity because it is constantly rubbing against clothing.

Since, according to most people I asked, an uncircumcised penis affords more pleasure for both parties during sex, perhaps circumcision is part of a Puritan conspiracy to make sex ess enjoyable. Or, because the moistness of the uncircumcised penis acts as a natural lubricant during intercourse, perhaps circumcision is simply a vast Vaseline conspiracy!

In a young child the foreskin protects he head of the penis from irritation by the ammonia in urine. Sometimes this irritation results in a meatal ulcer, a condition found only in circumcised boys. In addition, Ritter’s disease (a staphylococcal skin infection) and meatal stenosis (a narrowing and obstruction of the opening of the urethra at the head of the penis) also occur only in the circumcised.

Arguments for circumcision

But what are the arguments most commonly advanced for circumcision? The diseases associated with an uncircumcised penis are phimosis, cancer of the cervix, and cancer foreskin the penis. But many doctors now think that these fears are based on false premises.

Phimosis

Phimosis, the inability to retract the foreskin, was found to be normal in infants; in four out of five six-month-old males, half of the one-year-olds and 10 per cent of the three-year-olds, the foreskin is still attached to the head of the penis (Gairdner 1949). At the age of four or five, separation can be completed, if necessary by gently manipulation or with a probe.

Cervical cancer

Cancer of the cervix was thought to be caused by an uncircumcised penis, since Jewish women rarely got the disease and nearly all Jewish men are circumcised. Many doctors have discredited this theory, however, In Germany, Scandinavia, Switzerland and Japan, where circumcision is the exception, the incidence of cervical cancer is the same or less than in the United States, where circumcision is the rule.

A study in India showed that although Muslim women, whose men are usually circumcised in youth, did get less cancer of the cervix than the Hindus, the Parsee women and the Indian Christian women, who attach great importance to cleanliness, got even less cancer of the cervix than the Moslems, and their men are never circumcised (Khanolkar 1950). In England a study showed no difference in the circumcision status of the husbands of 54 cervical cancer patients and 54 controls (Aitken-Swan and Baird 1965), and an American study had similar results (Terris et al 1973). An investigation in Kenya revealed no significant differences in the number of cases of cervical cancer in women of tribes whose men were or were not circumcised (Preston 1970). In Ethiopia the incidence of cancer of the cervix is higher than or comparable to that of Europe and the United states, even though 90 per cent of Ethiopian males are ritually circumcised (Leitch 1970).

Other variables, besides the absence of circumcision, have been associated with a high risk of developing cervical cancer. These include low socio-economic status, early marriage, multiple marriages, extramarital relations, coitus at an early age, frequent coitus, non-use of contraceptives, syphilis and multiparity [i.e. having many children] (Preston 1970).

The assumption is that smegma, present under the foreskin, is cancer-producing. However, this disease was unaffected by the use of a condom, which should protect the women from smegma (Leitch 1970). At any rate, having a circumcised husband is no insurance against cervical cancer, since even virgins get it, as do women who only have sexual relations with circumcised men. Also, Jewish women are more susceptible mow than they were at the beginning of the century, a difficult fact to explain (Wynder et al 1954).

Cancer of the penis

Cancer of the penis, a rare condition, is the only serious disease related to lack of circumcision. Only seven cases of penile cancer have been reported in western countries in men circumcised in infancy (Leitch 1970). However, the Zulus have a high rate, even though they practise routine circumcision (Klauber 1973). [NOTE: In South Africa it is the Xhosa who practise circumcision, traditionally on boys in their late teens, not the Zulus.]

Again, attempts have been made to implicate smegma, an obvious approach, since it is secreted under the foreskin, and thus only by uncircumcised men. However, these researchers have always reported negative results (Weiss 1964; Heins et al 1958; Fishman 1942). It is seldom mentioned than women also have foreskins and smegma-producing glands, and face a more difficult problem keeping the clitoral region free from smegma (if indeed any women considers she is dong this at all), since the clitoris is such a small organ compared to the penis of the male. Yet, cancer of the clitoris is extremely rare.

More likely other factors are more important in causing penile cancer: a noon-retractable foreskin, which is the case in over half the males having cancer of the penis (Hanash et al 1970); a congenitally tight or long redundant foreskin (Leitch 1970; Lenowitz and Graham 1946; Dean 1935; Wolbarst 1932); poor hygiene, promiscuity, lack of prophylaxis, and failure to obtain treatment for minor inflammatory penile lesions (Schrek and Lenowitz 1947).

It would seem that if a man can retract his foreskin and does keep it clean, the risk of cancer is virtually removed (Jolly 1964; Gairdner 1949). In Scandinavia and Puerto Rico, where very few men are circumcised, the incidence of cancer of the penis is very low. Cancer of the penis can be treated if a doctor is seen right away. Most severe cases are not seen by any doctor until the disease is so far developed that it is too late to do anything.

Preventive surgery an old fashioned fad

Circumcision is the only preventive operation left in American medicine; the automatic removal of tonsils, appendix and adenoids went out of style years ago – though more lives could be saved by routine appendectomy (advocated by nobody) than by routine circumcision. Also, bilateral simple mastectomy (removal of the breasts) in young girls would prevent far more breast cancer in later years than the penile cancer prevented by circumcision. “If a surgeon should perform one circumcision every 10 minutes, eight hours a day, five days a week, he would seem to be able to prevent one penile cancer by working steadily for between six and 29 years. Since a significant number of penile cancers are curable, still more time and labour might be required to prevent a fatality from this disease” (Marshall 1954).

How many smokers pay any attention to the warnings about lung cancer? Most of them believe that the pleasure they get outweighs the higher risk of lung cancer – a cancer far more deadly and non-treatable than cancer of the penis.

Infection of the foreskin is another problem supposedly associated with non-circumcision. These infections are usually not serious, however, and not one of the uncircumcised men I interviewed mentioned any such problem.

“Hygiene” is the most bizarre reason given for circumcision. What other part of your body would you consent to have surgically removed so that you would not have to wash it? Would you have all your fingernails and toenails pulled out so that dirt could not collect under them? Would you have your ear or your nose cut off so that you would not have to clan inside them? Surely the penis is an equally important part of the body, yet parents permit part of it to be cut off so that their sons will not have so much trouble cleaning it!

Risks and complications

The circumcision operation itself can result in infection and other complications; some complication occurred in 55 per cent of the babies in one study (Patel 1966). The infections following circumcision are usually mild, but thy can result in serious and sometimes fatal conditions, such as diphtheric infection of the wound, staphylococcal bronchopneumonia, staphylococcal septiceaemia resulting in osteomyelitis of the femur, tetanus, tuberculosis or urethritis (Byars and Trier 1958), and necrosis of the penis (Gallagher 1972).

Other complications of circumcision arise from mistakes made by the doctor. They an result in deformity or dysfunction of the penis itself, and often require surgical repair. These include accidental amputation, cautery burns, bivalving of the glans, urethral fistula, concealed penis and erysipeloid infections (Burger 1974). Circumcision is often performed by inexperienced physicians or interns. One doctor says that on his daily hospital rounds in New York he frequently finds babies with ugly granulating wounds and others requiring surgical treatment to stop the bleeding. Many of these results are (more or less) remedied by the hospital staff without ever bringing them to the attention of the babies’ parents.

And then the pain and trauma of the operation should not be ignored. Although parents want to believe that the child will feel no pain, many doctors who have done circumcision operations vehemently deny this myth. It is normal for a boy to have an erection following the circumcision, which can separate the wound (Gottlieb). So on top of everything else, his first erection would be a painful one – more trauma. Beside this, the head of the penis is at first so sensitive that it may bleed from rubbing on the diaper.

Care of the uncircumcised penis

An uncircumcised child must be properly cared for. First, it’s not necessary (in fact, it’s dangerous), to pull back the foreskin of a baby, no matter what your doctor tells you. The child does not need to be cleaned under the foreskin at this age. If his urine is coming out in a stream and not under pressure, then he is normal. If you forcibly retract the foreskin of a baby you can cause the head of the penis to be strangulated, a condition called paraphimosis, since the hole at that time is only large enough to allow urine to come through. It may be impossible to return the foreskin to its natural position, and the baby will have to be rushed to hospital for an operation. You can also tear the tissue that joins the foreskin to the head of the penis. When this tear heals the condition is called acquired phimosis: the foreskin and penis join together in scar tissue, making the foreskin non-retractable. After the age of four or five the area under the foreskin may be washed whenever the child bathes. No more attention has to be paid to cleaning this area than to cleaning other parts of the body.

If someone suggested that you have your daughter circumcised, a custom practised fairly extensively throughout the world, with some medical backing even here, you would not say, “OK, why not?”, but rather, “Why?” and expect a pretty good answer before you went ahead. Your son should be given as much consideration. The onus is on those who believe in circumcision to prove their case to you.

NOTE

This article is interesting as one of the first protests against circumcision to appear in the popular press by a non-professional – a New York journalist and mother who had been shocked at the idea of mutilating her child and who decided to look into the matter. The article is very much a product of its time, demonstrating how deeply decades of misinformation about the structure of the genitals and the causes of disease had seeped into popular understanding; even while rejecting the myth that circumcision was beneficial, the author accepted other myths – that the origins of ritual circumcision lay in hygienic concerns (the sand myth), that the glans of the penis was particularly rich in pleasure sensing nerves, that the function of the foreskin was to preserve this sensitivity, that the foreskin had to be retractable by the time the boy was four or five, that sub-preputial moisture (“smegma”) possibly was in some way harmful. (The reference to using a probe to separate foreskin from glans in a five-year-old boy is particularly unfortunate.) Today we would stress the ethical and human rights aspects of the problem – the child’s right to a whole body and to make his own decisions about his health, and the inherent value of the foreskin itself – as paramount; yet Topp makes no more mention of these issues than the various medicos she diligently cites.

Although the article cannot be taken as a reliable source of information about circumcision or advice on the care of the penis today, it is of great historical interest for three main reasons. First, it shows the poor state of 1970s medical knowledge about both the structure and function of the penis and the origins of diseases such as genital cancers (now known to be caused by a virus), and the extent to which doctors were still in the grip of Victorian myths. Second, it marks the point where the debate over the validity of routine circumcision moves out of the pages of the medical journals and into the popular media, no longer the exclusive preserve of the medically sanctified, but the property of an increasingly informed and critical public. Third, it indicates just how far, and in what ways, the debate over circumcision has advanced in the past quarter century; if there has been disappointingly little progress on the “pros and cons” side (enthusiasts still harp on about such hoary myths as cancer, venereal disease, phimosis) at least there is increasing awareness of the ethical issues and a willingness in major journals (such as the Journal of Medical Ethics) to challenge the practice.

For more up to date information

More up to date information on some of the issues discussed in this article may be found here: